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St. Matthew’s Youth Ministry Parent Guardian Release and Consent Form 105 Southville Rd Southborough, MA 01772 Rectory: 508 485-2285 Youth Ministry Office: 508 481-4923 Name of Youth: _______________________________Youth’s Email: ________________________ Address: ________________________________________________________________________________ I, _______________________, give permission for my son/daughter,________________ to participate in _________________________
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_____________________. I give permission for my daughter/son to be transported in privately owned and/or public vehicles transportation to and from the St. Matthew’s Youth Ministry event. In case of medical emergency, I understand that every effort will be made to contact the parent(s) or guardian(s) of my child. In the event that I cannot be reached, I give permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated by licensed medical personnel. In addition, I give permission for the release of any medical records, which I have provided to St. Matthew’s Youth Ministry and participating parishes, to medical personnel in case of illness. I hereby release St. Matthew’s Parish the Diocese of Worcester, their parishes, agents, volunteers and employees and all priest incardinated the Diocese of Worcester, from any and liabilities for personal property incident to this event and any aforementioned medical care and treatment which is provided. Emergency Contact Info: Parent/ Guardian Home Phone _________________ Cell Phone/ Beeper __________ Medical Insurance Carrier: Policy # Medical Info (allergies, seizures medications, etc.): I have read the foregoing and understand the same. Parent/Guardian signature:
____________________________________ Date:____________ |